A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
A 3-year-old child who has an atrial septal defect and a heart rate of 120/min
A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL
A 2-year-old child who has diarrhea and reports abdominal pain
The Correct Answer is A
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Use clean technique for invasive procedures is incorrect because clients with neutropenia require sterile technique for invasive procedures to minimize infection risk.
B. Allow healthy children to visit is incorrect because children can be asymptomatic carriers of infections, which can be life-threatening for immunocompromised clients.
C. Make sure the client's room is cleaned every 2 days is incorrect because a neutropenic client’s room should be cleaned daily to reduce exposure to pathogens.
D. Monitor the client's temperature every 4 hr is correct because even a slight fever can indicate infection, which can be life-threatening for a client with neutropenia. Frequent monitoring allows for early detection and intervention.
Correct Answer is D
Explanation
A. Varicella vaccine is given at 12–15 months and a second dose at 4–6 years. It is not given at 2 months.
B. Influenza vaccine is recommended annually starting at 6 months of age. It is not given at 2 months.
C. Hepatitis A vaccine is given at 12–23 months, with a second dose 6 months later. It is not given at 2 months.
D. Rotavirus vaccine is routinely given at 2 months and again at 4 months (and possibly 6 months depending on the vaccine type). This is the correct answer.
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